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2013-258 DSS-Senior Care of Orange County for Adult Day Health Services $20,000
�sf Contract#68-2014 Senior Care of Orange County,Inc. 5_- .�m Contract# 68-2014 Fiscal Year Begins Julyl,2013 Ends June 30,2014 This contract is hereby entered into by and between the Orange County Department of Social Services(the"County")and Senior Care of Orange County,Inc.(the"Contractor")(referred to collectively as the"Parties"). The Contractor's federal tax identification number or Social Security Number is 1. Contract Documents: This Contract consists of the following documents (1) This contract (2) The General Terms and Conditions(Attachment A) (3) The Scope of Work,description of services,and rate(Attachment B) (4) Federal Certification Regarding Drug-Free Workplace&Certification Regarding Nondiscrimination(Attachment C) (5) Conflict of Interest(Attachment D) (6) No Overdue Taxes(Attachment E) (7) HIPAA Business Associate Addendum(Attachment I) (8) Certification of Transportation(Attachment J) (9) IRS Federal Tax Exempt Letter or 501(c)(3)(Attachment K) (10)Outcomes and Reporting(Attachment N) (11)Contract Determination Questionnaire These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. 2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in Paragraph 1, above, with the first-listed document having the highest precedence and the last-listed document having the lowest precedence. If there ate multiple Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. 3. Effective Period: This contract shall be effective on July 1,2013 and shall terminate on June 30, 2014. This contract must be twelve months or less. 4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in Attachment B, Scope of Work,and shall meet the requirements set forth in Attachment N,Outcomes and Reporting. 5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract Documents. The total amount paid by the County to the Contractor under this contract shall not exceed$20,000. This amount consists of$20,000 in Federal (CFDA # ), State and County funds, $0 (source of other funds if applicable). [X] a. There are no matching requirements from the Contractor. [ ] b.The Contractor's matching requirement is$ ,which shall consist of: [ ] In-kind [ ] Cash [ ] Cash and In-kind [ ] Cash and/or In-kind The contributions from the Contractor shall be sourced from non-federal funds. The total contract amount including any Contractor match shall not exceed$20,000. 6. Reporting Requirements: Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22&23 and OMB Circular A-133. Contract-General (07/10) Page 1 of 4 Contract#68-2014 Senior Care of Orange County,Inc. 7. Payment Provisions: Payment shall be made in accordance with the Contract Documents as described in the Scope of Work, Attachment B. 8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. The name,post office address,street address,telephone number,fax number,and email address of the Parties'respective initial Contract Administrators are set out below. Either Party may change the name, post office address, street address, telephone number,fax number,or email address of its Contract Administrator by giving timely written notice to the other Party. For the County: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Denise Shaffer, Social Work Program Director Denise Shaffer, Social Work Program Director Orange County Department of Social Services Orange County Department of Social Services P.O. Box 8181 2501 Homestead Road Hillsborough,NC 27278 Chapel Hill,NC 27516 (919)968-2000 ext.246 (919)968-2012 dshaffer co.oran e.nc.us Program Contact: Renee Bynum,Adult Services Supervisor Orange County Department of Social Services P.O. Box 8181 113 Mayo Street Hillsborough,NC 27278 (919)245-2881 b num co.oran e.nc.us For the Contractor: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Alvonia Baldwin Alvonia Baldwin Florence Gray Soltys Adult Day Health Program Florence Gray Soltys Adult Day Health Program P.O. Box 8181 105 Meadowland Drive Hillsborough,NC 27278 Hillsborough,NC 27278 (919)245-2017 (919)245-2018 albaldwin co.oran e.nc.us Contract-General (07/10) Page 2 of 4 Contract#68-2014 Senior Care of Orange County,Inc. 9. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this Agreement or make any assignment of this Agreement(including rights to payments)without the prior written Consent of the County as specified more fully in Attachment A,General Terms and Conditions. 10. Supplementation of Expenditure of Public Funds: The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract services and related programs.Funds received under this contract shall be used to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total expenditure of other public funds for such services. 11. Disbursements: As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in accordance with the following requirements: a. Implement adequate internal controls over disbursements; b. Pre-audit all vouchers presented for payment to determine: i. Validity and accuracy of payment ii. Payment due date iii. Adequacy of documentation supporting payment iv. Legality of disbursement c. Assure adequate control of signature stamps/plates; d. Assure adequate control of negotiable instruments;and e. Implement procedures to insure that account balance is solvent and reconcile the account monthly. 12. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County all jobs related to the contract that have been outsourced to other countries,if any. The Contractor further agrees that it will not outsource any such jobs during the term of this contract without providing notice to the County. 13. Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain certifications required by federal laws and regulations. The contractor is hereby complying with Certifications regarding Nondiscrimination, Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and certifications are to be signed by the contractor's authorized representative. 14. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has or will secure,at its own expense,all personnel required in performing the services under this Agreement. Such personnel shall not be employees of or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services. It is further agreed by Contractor that it shall obey all State and Federal statutes,rules and regulations which are applicable to provisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an officer,employee or agent of the County. 15. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement. The Contractor and the County have executed this contract in duplicate originals,with one original being retained by each party. Contract-General (07/10) Page 3 of 4 Contract#68-2014 Senior Care of Orange County,Inc. SENI R CARE OF ORANGE COUNTY,INC. UA�t'=� OnA041.1- o Signature Date �;11/yVlll�- �aWtrf "DI/'CG Printed Name Title ORANGE COUNTY Frank lifton,J r ounty Manager Date This instrument has been approved as to technical content. 01 n�s�t3 Nancy Costo ,Dep ent of Social Services Director Date This instrument has been pre- dited in the manner required by the Local Government Budget and Fiscal Control Act. Nt� �0 Mme- ql r*F//-? Clarence G.Grier,Asst. County Manager/CFO bate This o act een approved as to form and legal sufficiency. Anne e M. re, Staff Athmey Datb Contract-General (07/10) Page 4 of 4 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT A GENERAL TERMS AND CONDITIONS Orange County Department of Social Services Relationships of the Parties under this contract shall be deemed an incidental Independent Contractor: The Contractor is and shall be beneficiary only. deemed to be an independent contractor in the performance of this contract and as such shall be wholly responsible for Indemnity and Insurance the work to be performed and for the supervision of its employees. The Contractor represents that it has,or shall Indemnification: The Contractor agrees to indemnify and secure at its own expense, all personnel required in hold harmless the County and any of their officers,agents performing the services under this agreement. Such and employees,from any claims of third parties arising out employees shall not be employees of, or have any or any act or omission of the Contractor in connection with individual contractual relationship with the County. the performance of this contract. Subcontracting: The Contractor shall not subcontract any Insurance: During the term of the contract,the Contractor of the work contemplated under this contract without prior at its sole cost and expense shall provide commercial written approval from the County. Any approved insurance of such type and with such terms and limits as subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a contract.Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the documents are to be considered approved upon award of following coverage and limits: the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation The Contractor shall be responsible for the performance of Insurance as required by the laws of North all of its subcontractors. Carolina,as well as employer's liability coverage with minimum limits of$500,000.00,covering all Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to request approved by the issuing purchasing authority,the provide the same coverage for any of his County may: employees engaged in any work under the (a) Forward the Contractor's payment check(s) contract. directly to any person or entity designated by the (b) Commercial General Liability - General Contractor,or Liability Coverage on a Comprehensive Broad (b) Include any person or entity designated by Form on an occurrence basis in the minimum Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined Single Limit. payment check(s). (Defense cost shall be in excess of the limit of In no event shall such approval and action obligate the liability.) County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor Contractor shall remain responsible for fulfillment of all shall provide automobile liability insurance with a contract obligations. combined single limit of$500,000.00 for bodily injury and property damage; a limit of Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist otherwise,this contract shall inure to the benefit of and be coverage; and a limit of$25,000.00 for medical binding upon the parties hereto and their respective payment coverage. The Contractor shall provide successors. It is expressly understood and agreed that the this insurance for all automobiles that are: enforcement of the terms and conditions of this contract, (a) owned by the Contractor and used in the and all rights of action relating to such enforcement,shall performance of this contract; be strictly reserved to the County and the named (b) hired by the Contractor and used in the Contractor.Nothing contained in this document shall give performance of this contract;and or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and other third person.It is the express intention of the County used in performance of this contract("non- and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned the County or the Contractor,receiving services or benefits vehicle insurance protects employers when General Terms and Conditions—(07/10) Page 1 of 4 Contract#68-2014 Senior Care of Orange County,Inc. employees use their personal vehicles for Termination Without Cause: The County may terminate work purposes. Non-owned vehicle this contract without cause by giving 30 days written insurance supplements, but does not notice to the Contractor. replace,the car-owner's liability insurance. Termination for Cause: If, through any cause, the The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this automobile liability insurance on any vehicle—owned, contract in a timely and proper manner, the County shall hired,or non-owned--unless the vehicle is used in the have the right to terminate this contract by giving written performance of this contract. notice to the Contractor and specifying the effective date (d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished deliverable subparagraph(a)are exclusive of defense costs. items prepared by the Contractor under this contract shall, (e) The Contractor understands and agrees that the at the option of the County, become its property and the insurance coverage minimums specified in Contractor shall be entitled to receive just and equitable subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on such Contractor's liability or obligations under this contract. materials,minus any payment or compensation previously (f) The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, the of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the County demonstrating that it has insurance that provides for damages sustained by the County by virtue of the protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County may and limits specified in subparagraph(a). The County withhold any payment due the Contractor for the purpose shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damages should be granted. due the County from such breach can be determined. In (g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting any of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County may that it is self-insured and that its self-insurance procure the contract services from other sources and hold provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasioned coverage and Iimits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by the County shall be the sole judge of whether such a Contractor shall be an act of default under this contract. waiver should be granted. (h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any default insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract by is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of any essence of this contract. subsequent default or breach and shall not be construed to (i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless stated companies that are authorized to provide such to be such in writing, signed by an authorized coverage and that are authorized by the Commissioner representative of the County and the Contractor and of Insurance to do business in the State of North attached to the contract. Carolina.All such insurance shall meet all laws of the State of North Carolina. Availability of Funds: The parties to this contract agree (j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified in terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subject lawful requirements of its insurer. to the appropriation, allocation, and availability of funds (k) The Contractor shall require its subcontractors to for this purpose to the County. comply with the requirements of this paragraph. (1) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be in the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it is certificates of insurance to the County before the prevented from performing such obligations by any act of Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes, civil insurrection,earthquake,hurricane,tornado,or other Transportation of Clients by Contractor: catastrophic natural event or act of God. The contractor will maintain Insurance requirements if required as noted under Article 7 Rule R2-36 of the North Survival of Promises: All promises,requirements,terms, Carolina Utilities Commission. conditions, provisions, representations, guarantees, and Default and Termination warranties contained herein shall survive the contract expiration or termination date unless specifically provided General Terms and Conditions—(07/10) Page 2 of 4 Contract#68-2014 Senior Care of Orange County,Inc. otherwise herein, or unless superseded by applicable Confidentiality: Any information, data, instruments, Federal or State statutes of limitation. documents, studies or reports given to or prepared or assembled by the Contractor under this agreement shall be Intellectual Property Rights kept as confidential and not divulged or made available to any individual or organization without the prior written Copyrights and Ownership of Deliverables: All approval of the County.The Contractor acknowledges that deliverable items produced pursuant to this contract are the in receiving,storing,processing or otherwise dealing with exclusive property of the County. The Contractor shall not any confidential information it will safeguard and not assert a claim of copyright or other property interest in further disclose the information except as otherwise such deliverables. provided in this contract. Federal Intellectual Property Bankruptcy Protection Oversight Act:The Parties agree that the County shall be entitled to all rights and benefits of the Federal Intellectual Property Access to Persons and Records: The State Auditor shall Bankruptcy Protection Act,Public Law 100-506,codified have access to persons and records as a result of all at 1 I U.S.C. 365 (n)and any amendments thereto. contracts or grants entered into by State agencies or political subdivisions in accordance with General Statute Compliance with Applicable Laws 147-64.7. Additionally,as the State funding authority,the Department of Health and Human Services shall have Compliance with Laws: The Contractor shall comply access to persons and records as a result of all contracts or with all laws, ordinances, codes, rules, regulations, and grants entered into by State agencies or political licensing requirements that are applicable to the conduct of subdivisions. its business, including those of federal, state, and local agencies having jurisdiction and/or authority. Record Retention: Records shall not be destroyed, purged or disposed of without the express written consent Title VI,Civil Rights Compliance: In accordance with of the County. The North Carolina State basic records Federal law and U.S.Department of Agriculture(USDA) retention policy requires all grant records to be retained for and U.S. Department of Health and Human Services a minimum of five years or until all audit exceptions have (HHS) policy, this institution is prohibited from been resolved, whichever is longer. If the contract is discriminating on the basis of race,color,national origin, subject to federal policy and regulations,record retention sex, age or disability. Under the Food Stamp Act and may be longer than five years since records must be USDA policy, discrimination is prohibited also on the retained for a period of three years following submission of basis of religion or political beliefs. the final Federal Financial Status Report,if applicable,or three years following the submission of a revised final Equal Employment Opportunity: The Contractor shall Federal Financial Status Report. Also, if any litigation, comply with all federal and State laws relating to equal claim, negotiation, audit, disallowance action, or other employment opportunity. action involving this Contract has been started before expiration of the five-year retention period described Health Insurance Portability and Accountability Act above,the records must be retained until completion of the (HIPAA): The Contractor agrees that,if the County action and resolution of all issues which arise from it, or determines that some or all of the activities within the until the end of the regular five-year period described scope of this contract are subject to the Health Insurance above,whichever is later. Portability and Accountability Act of 1996,P.L. 104-91, as amended("HIPAA"),or its implementing regulations, Warranties and Certifications it will comply with the HIPAA requirements and will execute such agreements and practices as the County Date and Time Warranty: The Contractor warrants that may require to ensure compliance. the product(s) and service(s) furnished pursuant to this contract("product'includes,without limitation,any piece Trafficking Victims Protection Act of 2000 : of equipment,hardware,firmware,middleware,custom or The Contractor will comply with the requirements of commercial software,or internal components,subroutines, Section 106(g)of the Trafficking Victims Protection Act and interfaces therein)that perform any date and/or time of 2000,as amended(22 U.S.C.7104) data recognition function, calculation,or sequencing will support a four digit year format and will provide accurate Confidentiality date/time data and leap year calculations. This warranty shall survive the termination or expiration of this contract. General Terms and Conditions—(07/10) Page 3 of 4 Contract#68-2014 Senior Care of Orange County,Inc. Executive Order#24: It is unlawful for any vendor, Certification Regarding Collection of Taxes: G.S. 143- contractor, subcontractor or supplier of the state to make 59.1 bars the Secretary of Administration from entering gifts or to give favors to any state employee. For into contracts with vendors that meet one of the conditions additional information regarding the specific of G.S. 105-164.8(b)and yet refuse to collect use taxes on requirements and exemptions,contractors are sales of tangible personal property to purchasers in North encouraged to review Executive Order 24 and G.S. Sec. Carolina. The conditions include: (a) maintenance of a 133-32. retail establishment or office; (b) presence of representatives in the State that solicit sales or transact Key Personnel: The Contractor shall not replace any of business on behalf of the vendor; and (c) systematic the key personnel assigned to the performance of this exploitation of the market by media-assisted, media- contract without the prior written approval of the County. facilitated, or media-solicited means. The Contractor The term "key personnel" includes any and all persons certifies that it and all of its affiliates (if any) collect all identified as such in the contract documents and any other required taxes. persons subsequently identified as key personnel by the written agreement of the parties. Miscellaneous Care of Property: The Contractor agrees that it shall be Choice of Law: The validity of this contract and any of its responsible for the proper custody and care of any property terms or provisions,as well as the rights and duties of the furnished to it for use in connection with the performance parties to this contract,are governed by the laws of North of this contract and will reimburse the County for loss of, Carolina.The Contractor,by signing this contract,agrees or damage to, such property. At the termination of this and submits,solely for matters concerning this Contract,to contract, the Contractor shall contact the County for the exclusive jurisdiction of the courts of North Carolina instructions as to the disposition of such property and shall and agrees, solely for such purpose, that the exclusive comply with these instructions. venue for any legal proceedings shall be Orange County, North Carolina. The place of this contract and all Travel Expenses: Reimbursement, if provided in this transactions and agreements relating to it, and their situs Agreement, to the Contractor for travel mileage, meals, and forum,shall be Orange County,North Carolina,where lodging and other travel expenses incurred in the all matters,whether sounding in contract or tort,relating to performance of this contract shall not exceed the rates the validity,construction,interpretation,and enforcement established in County policy. shall be determined. Sales/Use Tax Refunds: If eligible,the Contractor and all Amendment: This contract may not be amended orally or subcontractors shall: (a) ask the North Carolina by performance. Any amendment must be made in written Department of Revenue for a refund of all sales and use form and executed by duly authorized representatives of taxes paid by them in the performance of this contract, the County and the Contractor. pursuant to G.S. 105-164.14; and (b) exclude all refundable sales and use taxes from all reportable Severability: In the event that a court of competent expenditures before the expenses are entered in their jurisdiction holds that a provision or requirement of this reimbursement reports. contract violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it Advertising: The Contractor shall not use the award of is not in violation of law or is not otherwise unenforceable this contract as a part of any news release or commercial and all other provisions and requirements of this contract advertising. shall remain in full force and effect. Orange County Living Wage: Orange County is Headings: The Section and Paragraph headings in these committed to providing its employees with a living wage General Terms and Conditions are not material parts of the and encourages agencies to which it provides funding to agreement and should not be used to construe the meaning pursue the same goal. The County's living wage hourly thereof. standard,as adopted by the Orange County Board of County Commissioners annually,can be found in the Time of the Essence: Time is of the essence in the Orange County Budget Ordinance. To the extent performance of this contract. possible, Orange County recommends that the Contractor and all subcontractors provide a living wage, as defined in this section,to their employees General Terms and Conditions—(07/10) Page 4 of 4 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT B SCOPE OF WORK Orange County Department of Social Services Federal Tax Id.or SSN Contract# 68-2014 A. CONTRACTOR INFORMATION 1. Contractor Agency Name: Senior Care of Orange County Inc. 2. Ifdifferent from Contract Administrator Information in General Contract: Address I05 Dr. t?, O- 'P:�ax kl Ijl Telephone Number:_9115-29S-201-7 Fax Number:_415'$RS191kmail: 3. Name of Program(s): Adult Da Health Service 4. Status: ( )Public (X)Private,Not for Profit ( )Private,For Profit 5. Contractor's Financial Reporting Year July 1,2013 through June 30,2014 B. Explanation of Services to be provided and to whom(include SIS Service Code): The Contractor will provide Adult Day Health Services(SIS Code 091)to clients of the Orange County Department of Social Services These services will include assistance with Activities of Daily Living,health monitoring by an RN and therapeutic recreational programs The Contractor is required to meet all goals and outcomes listed in Attachment N C. Rate per unit of Service(define the unit): 1. If Standard Fixed Rate,Maximum Allowable,(See Rates for Services Chart) Minimum daily rate:$38.92/day per client 2.Negotiated County Rate. D. Number of units to be provided: E.Details of Billing process and Time Frames; The County will reimburse the Contractor for services described in this contract up to the budgetary limits of the contract allotment The County will reimburse the Contractor at a rate of$38.92/dgy for approved services provided For reimbursement,the Contractor must submit an original and two copies of an invoice by the fifth of the month for the preceding month's expenditures to the designated County Administrator. The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed report. The service(s)under contract with the Contractor are services for which a client may voluntarily contribute to the cost. Policies regarding the solicitation and acceptance of voluntary contributions are contained in Family Services Manual Volume VI Chapter III If a client Contract-Scope of Work(06/04) Page lof 2 Contract#68-2014 Senior Care of Orange County,Inc. voluntarily contributes to the cost of service,the County will inform the Contractor of the amount of the contribution and of any subsequent changes. The Contractor will establish a plan with the client for accepting the contribution on at least a monthly basis, when contributions are not received within ten days of the agreed upon date will notify the client in writing and send a copy of the notification to the County. No other fees for services may be charged to the client Client contributions are to be reported monthly to the County. F.Area to be served/Delivery site(s): Orange County Nancy C stop, is ervices Director (Signature of Contractor) c f�-ors ', 1 15 (Date Submitted) (Date Submitt d) Contract-Scope of Work(06/04) Page 2of 2 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT C CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS AND CERTIFICATION REGARDING NONDISCRIMINATION Orange County Department of Social Services I. By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by: A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; B. Establishing a drug-free awareness program to inform employees about: (1)The dangers of drug abuse in the workplace; (2)The Contractor's policy of maintaining a drug-free workplace; (3)Any available drug counseling,rehabilitation,and employee assistance programs;and (4)The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; C. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of the statement required by paragraph(A); D. Notifying the employee in the statement required by paragraph(A)that,as a condition of employment under the agreement,the employee will: (1)Abide by the terms of the statement;and (2)Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; E. Notifying the County within ten days after receiving notice under subparagraph(D)(2)from an employee or otherwise receiving actual notice of such conviction; F. Taking one of the following actions,within 30 days of receiving notice under subparagraph (D)(2),with respect to any employee who is so convicted: (1)Taking appropriate personnel action against such an employee, up to and including termination;or (2)Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State,or local health, law enforcement,or other appropriate agency;and Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs(A),(B),(C),(D),(E),and(F). Federal Certification-Drug-Free Workplace(07/10) Page 1 of 2 Contract#68-2014 Senior Care of Orange County,Inc. II. The site(s)for the performance of work done in connection with the specific agreement are listed below: 1. l d 6 M ec _Dr;✓e. (Street address) HiPsbo>rougk . NC 2,7Vf( (City,county,state,zip code) 2. (Street address) (City,county, state,zip code) Contractor will inform the County of any additional sites for performance of work under this agreement. False certification or violation of the certification shall be grounds for suspension of payment,suspension or termination of grants,or government-wide Federal suspension or debarment(45 C.F.R. Section 82.510. Section 4 CFR Part 85, Section 85.615 and 86.620). CERTIFICATION REGARDING NONDISCRIMINATION The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination.These include but are not limited to: (a)Title VI of the Civil Rights Act of 1964(P.L. 88-352)which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972,as amended(20 U.S.C. §§1681-1683,and 1685-1686), which prohibits discrimination on the basis of sex; (c)Section 504 of the Rehabilitation Act of 1973,as amended(29 U.S.C. §794),which prohibits discrimination on the basis of handicaps; (d)the Age Discrimination Act of 1975, as amended(42 U.S.C. §§6101-6107),which prohibits discrimination on the basis of age; (e)the Drug Abuse Office and Treatment Act of 1972(P.L. 92-255), as amended,relating to nondiscrimination on the basis of drug abuse;(f)the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970(P.L. 91-616), as amended,relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g)Title VIII of the Civil Rights Act of 1968(42 U.S.C. §§3601 et seq.),as amended, relating to nondiscrimination in the sale,rental or financing of housing; (h)the Food Stamp Act and USDA policy,which prohibit discrimination on the basis of religion and political beliefs; and(i)the requirements of any other nondiscrimination statutes which may apply to this Agreement. Signature Title e4 V'r z �3 Agency/Organization ate (Certification signature should be same as Contract signature.) Federal Certification-Drug-Free Workplace(07/10) Page 2 of 2 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT D CONFLICT OF INTEREST POLICY Orange County Department of Social Services The Board of Directors/Trustees or other governing persons, officers, employees or agents are to avoid any conflict of interest, even the appearance of a conflict of interest. The Organization's Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to always act in the best interest of the organization. This obligation requires that any Board member or other governing person, officer, employee or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission. At all times, Board members or other governing persons, officers, employees or agents, are prohibited from using their job title, the Organization's name or property, for private profit or benefit. A. The Board members or other governing persons, officers, employees, or agents of the Organization should neither solicit nor accept gratuities, favors, or anything of monetary value from current or potential contractors/vendors, persons receiving benefits from the Organization or persons who may benefit from the actions of any Board member or other governing person, officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising- activities. B. A Board or other governing body member may, with the approval of Board or other governing body, receive honoraria for lectures and other such activities while not acting in any official capacity for the Organization. Officers may, with the approval of the Board or other governing body, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. Employees may, with the prior written approval of their supervisor, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. If a Board or other governing body member, officer, employee or agent is acting in any official capacity, honoraria received in connection with activities relating to the Organization are to be paid to the Organization. C. No Board member or other governing person, officer, employee, or agent of the Organization shall participate in the selection, award, or administration of a purchase or contract with a vendor where,to his knowledge,any of the following has a financial interest in that purchase or contract: 1. The Board member or other governing person,officer,employee,or agent; 2. Any member of their family by whole or half blood, step or personal relationship or relative-in-taw; 3. An organization in which any of the above is an officer, director, or employee; 4. A person or organization with whom any of the above individuals is negotiating or has any arrangement concerning prospective employment or contracts. D. Duty to Disclosure-- Any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest is to be reported to the Board or other governing body or one's supervisor immediately. E. Board Action --When a conflict of interest is relevant to a matter requiring action by the Board of Directors/Trustees or other governing body,the Board member or other governing person, officer,employee, or agent(person(s))must disclose the existence of the conflict of interest and be given the opportunity to disclose all material facts to the Board and members of Conflict of Interest Policy(06/04) Pagel of 3 Contract#68-2014 Senior Care of Orange County,Inc. committees with governing board delegated powers considering the possible conflict of interest. After disclosure of all material facts, and after any discussion with the person, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. In addition,the person(s)shall not participate in the final deliberation or decision regarding the matter under consideration and shall leave the meeting during the discussion of and vote of the Board of Directors/Trustees or other governing body. F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other governing body has reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such belief and afford the person an opportunity to explain the alleged failure to disclose. If, after hearing the person's response and after making further investigation as warranted by the circumstances, the Board of Directors/Trustees or other governing body determines the member, officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. G. Record of Conflict -- The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: SGVIio✓ Ca✓Q p-� ©raylee C00►? Name of Organization � Signature of Organizatio�n Official /a5//,5 ate Conflict of Interest Policy(06/04) Page 2 of 3 Contract#68-2014 Senior Care of Orange County,Inc. NOTARIZED CONFLICT OF INTEREST POLICY State of North Carolina County of Orange 1 sn�,A , Notary Public for said County and State, certify that Maca (� ^personally appeared before me this day and acknowledged that he/she is Y( �S!(�X.Y1� of 1pf 0-a(10 p-� 0 -QD } f and by that authority duly given and as the act of the corporation, affirmed that the foregoing Conflict of Interest Policy was adopted by the Board of Directors in a meeting held on the day of , Sworn to and subscribed before me this ,`Z ,0Ai u 1 XV9 ,aQ U= (Official Seal)Z Z Notary Public pUBL �sG;;F M Commission expires �rCt,% �� Conflict of Interest Policy(06/04) Page 3 of 3 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT E OVERDUE TAXES Orange County Department of Social Services Instructions: Grantee/Provider should complete this certification for all funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form must be provided to the County Department of Social Services. taG...Carc of Dom.-•fie Co,..,,.t,1; s�+c . Entity's Letterhead r loetnct 6-e-" Soll�s AA - pA,t 1}t�ll{p. ra'�u,.-. 10 5 la.,A '>r. [Date of Certification(mmddyyyy)] �ti�tsl oro �•, ^« 2-11-7 � 0Q 12,5(2013 To: Orange County Department of Social Services Certification: Sev%gpr(yreeFOra.,StCow,j�Tula. We certify that the [insert organization's name] does not have any overdue tax debts,as defined by N.C.G.S. 105-243.1',at the federal,State,or local level. We further understand that any person who makes a false statement in violation ofN.C.G.S. 143C-6-23(c)is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1(b). Sworn Statement: AUr-y Aan ✓e f-e► -D W 8J w r 1 to rso- [Name of Board Chair]and[Name of Second Authorizing Official] being duly sworn, say that we are the Board Chair nd Title�f the Se' on o z n Official],respectively,of[insert name'cr-n-.e�.a„�o�(o.,z of organization] of�i�y 'iri t`i'e State of °e4do a e ;`ai d that the foregoing certification is true,accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. [Te 7 f eco ,.A�u z,orizi,n�g#-O fficial]-t np ft.,i Sworn to and subscribed before me on the daZ,ofltW414tye$f said certification. �Q-�A __ �My ? r My Comrji con Expires��I y,&1 (Notary Signature and Seal) 0 pwp Zr G.S. 105-243.1 defines:Overdue tax debt.–Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer.The term does not include a tax debt,however,if the taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement." Overdue Taxes—(07/08) Page 1 of 1 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT I BUSINESS ASSOCIATE ADDENDUM Orange County Department of Social Services This Agreement is made effective the 2�day of TtArvf. , 20 1 j by and between Orange County ("Covered Entity") and Senior Care of Orange County, Inc. ("Business Associate") (collectively the"Parties"). 1. BACKGROUND a. Covered Entity and Business Associate are parties to a contract entitled #68-2014 (the "Contract"), whereby Business Associate agrees to perform certain services for or on behalf of Covered Entity. b. Covered Entity is an organizational unit of Orange County (the "County") that has been designated in whole or in part by the County as a health care component for purposes of the HIPAA Privacy and Security Rules. c. The relationship between Covered Entity and Business Associate is such that the Parties believe Business Associate is or may be a"business associate"within the meaning of the HIPAA Privacy and Security Rules. d. The Parties enter into this Business Associate Addendum to the Contract with the intention of complying with the HIPAA Privacy and Security Rules provision that a covered entity may disclose electronic protected health information or other protected health information to a business associate,and may allow a business associate to create or receive electronic protected heath information or other protected health information on its behalf,if the covered entity obtains satisfactory assurances that the business associate will appropriately safeguard the information. 2. DEFINITIONS Unless some other meaning is clearly indicated by the context,the following terms shall have the following meaning in this Agreement: a. "Electronic Protected Health Information"shall have the same meaning as the term "electronic protected health information"in 45 CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity. b. "HIPAA"means the Administrative Simplification Provisions, Sections 261 through 264, of the federal Health Insurance Portability and Accountability Act of 1996,Public Law 104-191. c. "Individual"shall have the same meaning as the term"individual"in 45 CFRI60.103 and shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g). d. "Privacy and Security Rules"shall mean the Standards for Privacy of Individually Identifiable Health Information and the Security Standards for the Protection of Electronic Protected Health Information set out in 45 CFR part 160 and part 164, subparts A and E. e. "Protected Health Information"shall have the same meaning as the term"protected health information"in 45 CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity. Contract-Scope of Work(07/08) Page lof 5 Contract#68-2014 Senior Care of Orange County,Inc. f. "Required By Law"shall have the same meaning as the term"required by law"in 45 CFR 164.103. g. "Secretary"shall mean the Secretary of the United States Department of Health and Human Services or his designee. h. "Security Incident'shall have the same meaning as the term"security incident"in 45 CFR 164.304. i. Unless otherwise defined in this Agreement,terms used herein shall have the same meaning as those terms have in the Privacy and Security Rules. 3. OBLIGATIONS OF BUSINESS ASSOCIATE a. Business Associate agrees to not use or disclose electronic protected health information or other protected health information other than as permitted or required by this Agreement or as required by law. b. Business Associate agrees to implement administrative,physical,and technical safeguards that reasonably and appropriately protect the confidentiality, integrity,and availability of the electronic protected health information and other protected health information that it creates,receives,maintains,or transmits on behalf of Covered Entity, as required by the Privacy and Security Rules. c. Business Associate agrees to mitigate,to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of electronic protected health information or other protected health information by Business Associate in violation of the requirements of this Agreement. d. Business Associate agrees to report to Covered Entity(i)any use or disclosure of electronic protected health information or other protected health information not provided for by this Agreement of which it becomes aware and(ii)any security incident of which it becomes aware. e. Business Associate agrees to ensure that any agent, including a subcontractor,to whom it provides electronic protected health information and/or other protected health information received from,or created or received by Business Associate on behalf of Covered Entity(i)agrees to be bound by the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such information,and(ii) agrees to implement reasonable and appropriate safeguards to protect such information. f. Business Associate agrees to provide access,at the request of Covered Entity,to electronic protected health information and other protected health information in a Designated Record Set to Covered Entity or,as directed by Covered Entity,to an individual in order to meet the requirements under 45 CFR 164.524. g. Business Associate agrees,at the request of Covered Entity,to make any amendment(s) to electronic protected health information and other protected health information in a Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR 164.526. h. Unless otherwise prohibited by law,Business Associate agrees to make internal practices, books,and records,including policies and procedures concerning electronic protected health information and other protected health information,relating to the use and disclosure of electronic protected health information and other protected health information received from,or created or received by Business Associate on behalf of, Covered Entity available to the Covered Entity,or to the Secretary, in a time and manner Contract-Scope of Work(07/08) Page 2of 5 Contract#68-2014 Senior Care of Orange County,Inc. designated by the Secretary,for purposes of the Secretary determining Covered Entity's compliance with the Privacy and Security Rules. i. Business Associate agrees to document such disclosures of electronic protected health information and other protected health information related to such disclosures as would be required for Covered Entity to respond to a request by an individual for an accounting of disclosures of electronic protected health information and other protected health information in accordance with 45 CFR 164.528,and to provide this information to Covered Entity or an individual to permit such a response. 4. PERMITTED USES AND DISCLOSURES a. Except as otherwise limited in this Agreement or by other applicable law or agreement, if the Contract permits,Business Associate may use or disclose electronic protected health information and other protected health information to perform functions,activities,or services for,or on behalf of, Covered Entity as specified in the Contract,provided that such use or disclosure: 1) would not violate the Privacy and Security Rules if done by Covered Entity;or 2) would not violate the minimum necessary policies and procedures of the Covered Entity. b. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the Contract permits,Business Associate may use electronic protected health information and other protected health information as necessary for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate. c. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the Contract permits,Business Associate may disclose electronic protected health information and other protected health information for the proper management and administration of the Business Associate,provided that: 1) disclosures are required by law; or 2) Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and will be used or further disclosed only as required by law or for the purpose for which it was disclosed to the person,and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached. d. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the Contract permits,Business Associate may use electronic protected health information and other protected health information to provide data aggregation services to Covered Entity as permitted by 45 CFR 164.504(e)(2)(i)(B). e. Notwithstanding the foregoing provisions,Business Associate may not use or disclose electronic protected health information or other protected health information if the use or disclosure would violate any term of the Contract or other applicable law or agreements. 5. TERM AND TERMINATION a. Term. This Agreement shall be effective as of the effective date stated above and shall terminate when the Contract terminates. b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate,Covered Entity may,at its option: Contract-Scope of Work(07/08) Page 3of 5 Contract#68-2014 Senior Care of Orange County,Inc. 1) Provide an opportunity for Business Associate to cure the breach or end the violation,and terminate this Agreement and services provided by Business Associate,to the extent permissible by law, if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity; 2) Immediately terminate this Agreement and services provided by Business Associate,to the extent permissible by law; or 3) If neither termination nor cure is feasible,report the violation to the Secretary as provided in the Privacy and Security Rules. c. Effect of Termination. 1) Except as provided in paragraph(2)of this section or in the Contract or by other applicable law or agreements, upon termination of this Agreement and services provided by Business Associate,for any reason,Business Associate shall return or destroy all electronic protected health information and other protected health information received from Covered Entity,or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to electronic protected health information and other protected health information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the electronic protected health information or other protected health information.. 2) In the event that Business Associate determines that returning or destroying the electronic protected health information or other protected health information is not feasible,Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction not feasible.Business Associate shall extend the protections of this Agreement to such electronic protected health information and other protected health information and limit further uses and disclosures of such electronic protected health information and other protected health information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such electronic protected health information and other protected health information. 6. GENERAL TERMS AND CONDITIONS a. This Agreement amends and is part of the Contract. b. Except as provided in this Agreement,all terms and conditions of the Contract shall remain in force and shall apply to this Agreement as if set forth fully herein. c. In the event of a conflict in terms between this Agreement and the Contract,the interpretation that is in accordance with the Privacy and Security Rules shall prevail. In the event that a conflict then remains,the Contract terms shall prevail so long as they are in accordance with the Privacy and Security Rules. d. A breach of this Agreement by Business Associate shall be considered sufficient basis for Covered Entity to terminate the Contract for cause. Contract-Scope of Work(07/08) Page 4of 5 Contract#68-2014 Senior Care of Orange County,Inc. Nancy Cost n, go-cial Services Director (Signature of Contractor) o-)-OK-13 _ U 12,571 L5 _ (Date Submitted) (Date Submitted) Contract-HIPAA(06/04) Page 5 of 5 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT J CERTIFICATION REGARDING TRANSPORTATION Orange County Department of Social Services By execution of this Agreement the Contractor certifies that it will provide safe client transportation by: 1. Insuring that all drivers(including employees,contractors,contractor's employees,and volunteers)shall be at least 18 years of age; 2. Insuring that all drivers(including employees,contractors,contractor's employees,and volunteers)shall be licensed to operate the specific vehicle used in transporting clients in accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division of Motor Vehicle requirements; 3. Insuring that all vehicles transporting clients shall have at least the minimum level of liability insurance appropriate for the type of vehicle as defined by Article 7,Rule R2-36 of the North Carolina Utilities Commission; 4. Insuring that the contractor shall have written policies and procedures regarding how drivers handle and report client emergencies and/or vehicle crashes involving clients to contractor and how contractor notifies the Orange County Department of Social Services; 5. Contractor will maintain records documenting the following(County may require contractor to provide): a.Valid current copies of Drivers License for all drivers; b.Current valid Vehicle Registration, for all vehicles transporting clients; c.Driving records for all drivers for the past three years and with annual updates; d.Criminal Background checks through North Carolina Law Enforcement or NCIC prior to employment and every three years thereafter; e.Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines. 6. Disclosing, at the outset of the contract,upon renewal and upon request, any criminal convictions or other reasons for disqualifications from participation in Medicare,Medicaid or Title XX programs. Si ature on this form confirms this statement. 'D,ac. hr Signature Title Agency/Organization Date (Certification signature should be same as Contract signature.) Transportation Certification(05/09) Page 1 of 1 Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT K 501(c)(3)and TAX EXEMPT STATUS Orange County Department of Social Services What is a Private Non Profit Agency? Answer:A private non profit is an organization that is incorporated under State law and whose purpose is not to make a profit, but rather to further a charitable, civic, religious, scientific, or other lawful purpose. The Secretary of State's office grants corporate status to organizations in North Carolina. What is a 501(c)(3)designation? Answer: When the agency becomes a state private non profit corporation, it can then apply for 501(c)(3)designation through the IRS. Once the IRS grants 501(c)(3) status,the organization is exempt from certain taxes and any donations to the charitable organization are tax deductible. Many individuals and organizations prefer to make donations to 501(c)(3)private non profits. Who can obtain a 501(c)(3) designation? Answer:Any organization or group can apply for 501(c)(3) status,provided their charter or mission focuses on the non profit's objective. Another option is to apply for a 509(a)(1) status which falls under the 501(c)(3)umbrella. Being a 509(a)(1) designates an organization as a tax-free public charity that receives most of its support from a governmental unit or from the general public. Becoming a 509(a)(1)provides public recognition of tax-exempt status, advance assurance to donors of deductibility of contributions, exemption from certain State and federal taxes, and non profit mailing privileges. Organizations that typically qualify are churches, educational institutions, hospitals, and governmental units. To learn more about non profits, visit www.irs.gov, or call the tax-exempt helpline at 877-829- 4933. How does a Private Non Profit obtain Tax Exempt Status? A private non profit must apply to the IRS for tax exempt status. To qualify, applicants must complete and submit to the IRS Form 1023. Once federal tax exempt status is granted,the private non profit applies for State tax exempt status by completing Form CD-435 and submitting it to the N. C.Department of Revenue. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — - Please attach proof of 501(c)(3) or IRS tax-exempt status to this page. RS�TF3NU8 SERVICE DEPARTMENT OF p. O. I= 2506 ' a "CnTcnagA.TI, OR 45201 :, • --------�asplayesrldeatficat�oa R�anber= i- Date: JUL 2 DLN: . ... 17053159003034E S XCR CARR OF ORAVW CVUWfY 33C Contact Person: 3= 31522 57:5 14MADOWLAIM'IM STS 400 ZSR2A LUX g1LIS80ROUM, NC 27278 Contact Telephone 1Qumber- (877) 829-5500 Accounting Period Ending: JON 30 public Charity Status: 170(b) (1) (A) (v: ) Form 990 Required: YES Effectly Date of $?cCagation: = MRC13 29, 2aD4 Contri.bucion Deductibility: YES ��^; �,~, !'.;. �:,: :�:• . . - Advance Ruling $naliing Date: *77" •^,r. JUZ78 30, 2009 Dear ApplAcant_ -Ke re f 44WI f o%•ihfbr�a you that t rev7�ev pf your app"eatiaa �t4r tsX c,;. 1rC: r �``B? tZ1B•ws.�alsavc'BetAY*!±�,• that you are exempt from Federal income tax 01(E) (3)' •o£ the IntemTLA1 Revenue Code. Contributiams to you a�:e deductible.undeiti section 170 of the Code. You are also qu4xlified to receive r.�•,:r OZ = tax"' ductik►ls b eats; devises, transfers or gifts under section 2055, zz06 >k ;•r :.Ar:~ ar72527 'bfr'fbe;-U*di�.t7-BecaUGe this letter Could help reaulve X S�ulestioas i se•:•,. X0jaXdiEgmyourre t-•status, you should keep it in your pexvmaneat records. °Usgaaizatibas• t smaer section 501(c) (3) of the Code are further cla$sified •ci;c.; as'=eitb&r public chaxiities or private fou lotions. Dnxing your advance ruling �. period, you will be treated as a public rbarrity. Your advance ruling period begtua with the offective date of your exemption and ends with advance rQlLnug ending date shcAm in the heading of the 10tter. Shorty before the .end of your advance ruling period, we will send you Dorm 8734, Support Schedule for Advance Soling Period. You will have 90 days After the end of your advance ruling•period to xeturu the cowpleted form_ We will the;m notify yens, in writing, about your public charity status. Please see enclosed Information for Exempt Organizations Under Section 501(c) (3) for come helpful inf0mmaticu about your responsibilities as an eltemQt organization. Letter 1045 (DO/CG) i Contract#68-2014 Senior Care of Orange County,Inc. ATTACHMENT N OUTCOMES AND REPORTING Orange County Department of Social Services By signing and submitting this document,the Contractor certifies that it agrees to the following: 1.The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits, making records and staff time available to Federal, State and County staff. 2.The Contractor agrees to take necessary steps for corrective action,as negotiated within a corrective action plan,for any items found to be out of compliance with Federal, State,and County laws,regulations, standards and/or terms of the Contract. 3.The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the following requirements. The Contractor agrees to: A. Provide Adult Day Health Services,according to the North Carolina State Standards for Certification,to clients referred by the County. B. Comply with all State licensing standards,all applicable accrediting standards and any other standards or criteria established by the North Carolina Department of Health and Human Services to assure quality of services C. Maintain all financial and program records for a period of three years from the date of final payment under this agreement for inspection by the County,the Area Agency on Aging and the Comptroller General of the United States,or any of their duly authorized representatives. If any claim, litigation,negotiation,audit or other action involving the Contractor's records has been started before the expiration of the three-year period,the records must be retained until completion of the action and resolution of all issues that arise from it. D. Maintain appropriate program records,client case files which document the provision of the agreed upon service(s);and maintain a valid authorization for services for each client determined to be eligible by the County and authorized by the County for service(s)provided under this agreement. E. Furnish financial and program data as required to document the basis for the reimbursement rate and to document that applicable standards have been met. F. Be responsible for compliance with the audit requirements of the Department of Health and Human Services. a. An annual audit is to be performed in accordance with OMB Circular A-110 by an "independent auditor." "Independent auditor"means either: i. A state government auditor for the Department of Human Resources or the Department of Administration,Office of the State Auditor;or ii. A certified public accountant. b. Upon completion of the audit,a copy of the audit report must be forwarded to the County. G. Notify the County of participant absences of more than 5 days. H. Notify the County, in a timely manner,of significant changes in the clients' conditions or situations. Outcomes (06/04) Page 1 of 2 Contract#68-2014 l Senior Care of Orange County,Inc. Signature Title stf""o Gf'-C I Agency/Organs ion Date (Certification signature should be same as Contract signature.) Outcomes (06/04) Page 2 of 2